Validation of the potentially avoidable hospital readmission rate as a routine indicator of the quality of hospital care

BACKGROUND: The hospital readmission rate has been proposed as an important outcome indicator computable from routine statistics. However, most commonly used measures raise conceptual issues. OBJECTIVES: We sought to evaluate the usefulness of the computerized algorithm for identifying avoidable readmissions on the basis of minimum bias, criterion validity, and measurement precision. RESEARCH DESIGN AND SUBJECTS: A total of 131,809 hospitalizations of patients discharged alive from 49 hospitals were used to compare the predictive performance of risk adjustment methods. A subset of a random sample of 570 medical records of discharge/readmission pairs in 12 hospitals were reviewed to estimate the predictive value of the screening of potentially avoidable readmissions. MEASURES: Potentially avoidable readmissions, defined as readmissions related to a condition of the previous hospitalization and not expected as part of a program of care and occurring within 30 days after the previous discharge, were identified by a computerized algorithm. Unavoidable readmissions were considered as censored events. RESULTS: A total of 5.2% of hospitalizations were followed by a potentially avoidable readmission, 17% of them in a different hospital. The predictive value of the screen was 78%; 27% of screened readmissions were judged clearly avoidable. The correlation between the hospital rate of clearly avoidable readmission and all readmissions rate, potentially avoidable readmissions rate or the ratio of observed to expected readmissions were respectively 0.42, 0.56 and 0.66. Adjustment models using clinical information performed better. CONCLUSION: Adjusted rates of potentially avoidable readmissions are scientifically sound enough to warrant their inclusion in hospital quality surveillance.

Fluoxetine addition to methadone in addicts: pharmacokinetic aspects.

We report nine cases where fluoxetine (FX) (20 mg/day) was added to maintenance treatment with methadone (MTD) (dose range: 30-100 mg) in addicts with affective disorders. MTD plasma levels were measured before and after treatment with FX under steady-state conditions. Among the nine patients, two also received fluvoxamine (FLVX) at different times. Although it is possible that in some patients a moderate FX-MTD interaction occurs, resulting in increased plasma levels of MTD, this interaction is certainly less marked than that between FLVX and MTD and unlikely to have clinical consequences.

Avaliação da infestação de insetos-praga associados à batata (Solanum tuberosum L.) sob efeito de nutrientes nitrogenados e potássicos e teores acumulados de aminoácidos livres nas cultivares Achat e Monalisa

Evaluation of insect-pest infestation associated to potato (Solanum tuberosum L.) under effect of nitrogen and potassium fertilizers and the accumulated amount of free aminoacids in Achat and Monalisa cultivars. The objective of this work was to evaluate the occurence of insect-pests on potato plants influenced by dosages of nitrogen and potassium accumulated in plant organs. A total of 169 plants of the Achat and Monalisa cultivars were evaluated to determine the presence-absence of Diabrotica speciosa Germar, 1824 and Agrotis ipsilon Hüfnagel, 1767. The experiment was carried out and executed at the Universidade Federal Fluminense, and the delineation was complete randomized block design, with four replication and nine treatments, using three fertilization level (0; 75 and 150 Kg/ha) with N-urea + KCl. The aminoacid levels were adjusted by the Leucine standard-curve (µg/l), using the Ninhydrin method, at 570 nm. The results showed that the tubercles of Monalisa accumulated high free aminoacid levels with 7,95% in the treatment N1K2 and 7,75% in the N2K1.These treatments, induced the infestation by D. speciosa larvae in 27,03%, when the aminoacid level was 2,01 ± 0,58% (X ± EP), with probability of 0,0196

Konsuli Bror Sievers 10/11 1967

Kirje 10.11.1967

Qualidade da Água potável consumida nas cidades da Praia e Assomada

A água é um elemento imprescindível para a sustentação da vida na Terra. A garantia de consumo humano de água segundo padrões de qualidade adequados é uma questão relevante para a saúde pública. O presente trabalho tem como finalidade analisar a qualidade da água potável abastecida às populações das cidades da Praia e da Assomada. Para tal, foram realizadas análises dos parâmetros Organolépticos, físicos e químicos. Os métodos e técnicas utilizados durante a monitorização das análises foram as titulações, electrometria, turbidimetria, espectrometria e cálculos. Os resultados das análises das 20 amostras de águas colectadas nos principais reservatórios, furos de exploração e chafarizes de abastecimento às populações foram comparados com os valores máximos permissíveis para o consumo humano de acordo com os padrões da Organização Mundial de Saúde e da União Europeia. Com os últimos resultados das análises efectuadas em Dezembro de 2006 a uma amostra de água colectada no furo FBE 117 - Bolanha, na cidade de Assomada, detectou-se que os parâmetros físico-químicos analisados não atenderam os valores legais: Mineralização - 1.570; Condutividade - 1.851; Salinidade - 0,9; Magnésio - 1.261; Cloretos - 2.485. Com os registos frequentes de casos de doenças por Malária, Febre Tifóide, e Doenças Diarreicas a evidenciar uma possível contaminação da água potável, é necessário ampliar o período de estudo das análises de água abastecida para consumo, assim como a análise bacteriológica.

Campaign rhetoric: A model of reputation

We analyze conditions under which a candidate's campaignrhetoric may affect the beliefs of the voters over whatpolicy the candidate will implement in case he wins theelection. We develop a model of repeated elections withcomplete information in which candidates are purely ideological. Voter's strategies involve a credible threat to punish candidates that renege of their campaignpromises, and in equilibrium all campaign promises arebelieved by voters, and honored by candidates. We obtainthat the degree to which promises are credible in equilibriumis an increasing function of the value of a candidate'sreputation.

Skin problems associated with pegylated liposomal doxorubicin-more than palmoplantar erythrodysesthesia syndrome.

Liposomal pegylated doxorubicin is an encapsulation form of doxorubicin, with an improved pharmacokinetic profile and the ability to selectively accumulate into tumor tissue. As a result, the tolerated dose of the drug can be increased, followed by a reduced incidence of neutropenia and cardiotoxicity in comparison to doxorubucin treatment. However, a common adverse dose-schedule limiting effect of the treatment is palmoplantar erythrodysesthesia syndrome. In this retrospective study we included six patients hospitalised in the University Hospital of Zurich during the last 2 years, in connection with side effects caused by pegylated liposomal doxorubicin. These patients received this chemotherapeutic agent for treatment of various malignancies such as breast cancer, ovarian cancer, mycosis fungoides and cutaneous B-cell lymphoma. Three of six patients in this study developed classical palmoplantar erythrodysesthesia, one developed palmoplantar erythrodysesthesia associated with extensive bullous disease, one developed eruption of lymphocyte recovery syndrome and one developed intertrigo like dermatitis with stomatitis. Pegylated liposomal doxorubicin induces various skin reactions including palmoplantar erythrodysesthesia syndrome. However, the exact clinical presentation might depend on pre-existing skin diseases.

Color preference of Anastrepha obliqua (Diptera, Tephritidae)

The color preference of A. obliqua was evaluated in two-choice tests. The results showed that both sexes were attracted to wavelengths ranging from 340 nm to 670 nm, although the broad major peak of attraction occurred between 380 and 570 nm.

Mating triggers dynamic immune regulations in wood ant queens.

Mating can affect female immunity in multiple ways. On the one hand, the immune system may be activated by pathogens transmitted during mating, sperm and seminal proteins, or wounds inflicted by males. On the other hand, immune defences may also be down-regulated to reallocate resources to reproduction. Ants are interesting models to study post-mating immune regulation because queens mate early in life, store sperm for many years, and use it until their death many years later, while males typically die after mating. This long-term commitment between queens and their mates limits the opportunity for sexual conflict but raises the new constraint of long-term sperm survival. In this study, we examine experimentally the effect of mating on immunity in wood ant queens. Specifically, we compared the phenoloxidase and antibacterial activities of mated and virgin Formica paralugubris queens. Queens had reduced levels of active phenoloxidase after mating, but elevated antibacterial activity 7 days after mating. These results indicate that the process of mating, dealation and ovary activation triggers dynamic patterns of immune regulation in ant queens that probably reflect functional responses to mating and pathogen exposure that are independent of sexual conflict.

Late Pan-African magmatism in the Himalaya: new geochronological and geochemical data from the Ordovician Tso Morari metagranites (Ladakh, NW India)

Two granitic plutons, the Tso Morari gneiss and the Rupshu metagranite, crop out in the Tso Morari area. The Polokongka La granite, classically interpreted as a young intrusion in the Tso Morari gneiss, has been recognized as the undeformed facies of the latter. Conventional isotope dilution U-Pb zircon dating on single-grain and small multi-grain fractions yielded magmatic ages of 479 +/- 2 Ma for the Tso Morari gneiss and the Polokongka La granite, and 482.5 +/- 1 Ma for the Rupshu granite. There is a great difference in zircon morphology between the Tso Morari gneiss (peraluminous type) and the Rupshu granite (alkaline type). This difference is confirmed by whole-rock chemistry. The Tso Morari gneiss is a typical deformed S-type granite, resulting from crustal anatexis. On the other hand, the Rupshu granite is an essentially metaluminous alkali-calcic intrusion derived from a different source material. Data compilation from other Himalayan Cambro-Ordovician granites reveals huge and widespread magmatic activity all along and beyond the northern Indian plate between 570 and 450 Ma, with a peak at 500-480 Ma. A major, continental-scale tectonic event is required to generate such a large magmatic belt; it has been tentatively compared to the Variscan post-orogenic extensional regime of Western Europe, as a late evolution stage of a Pan-African orogenic event.

Escala de madurez gonadal de hembras de lenguado de ojo grande Hippoglossina macrops (Steindachner, 1876)

El lenguado de ojo grande Hippoglossina macrops es un recurso potencial poco estudiado. Tiene una amplia distribución latitudinal (3°S-8°S) y batimétrica (90-380 m de profundidad). Para determinar la escala de madurez gonadal, se analizaron 570 ovarios colectados en los Cruceros de Evaluación de Recursos Demersales de los años 2003 al 2007. Se determinó seis estadios de madurez gonadal: 0 (virginal), I (reposo), II (en maduración), III (maduro), IV (desovante), V (recuperación), los que permiten conocer con mayor certeza, la condición reproductiva de las hembras de esta especie y su principal periodo de reproducción.

Monitoring procalcitonin in febrile neutropenia: what is its utility for initial diagnosis of infection and reassessment in persistent Fever?

Background: Management of febrile neutropenic episodes (FE) is challenged by lacking microbiological and clinical documentation of infection. We aimed at evaluating the utility of monitoring blood procalcitonin (PCT) in FE for initial diagnosis of infection and reassessment in persistent fever.Methods: PCT kinetics was prospectively monitored in 194 consecutive FE (1771 blood samples): 65 microbiologically documented infections (MDI, 33.5%; 49 due to non-coagulase-negative staphylococci, non-CNS), 68 clinically documented infections (CDI, 35%; 39 deep-seated), and 61 fever of unexplained origin (FUO, 31.5%).Results: At fever onset median PCT was 190 pg/mL (range 30-26'800), without significant difference among MDI, CDI and FUO. PCT peak occurred on day 2 after onset of fever: non-CNS-MDI/deep-seated-CDI (656, 80-86350) vs. FUO (205, 33-771; p<0.001). PCT >500 pg/mL distinguished non-CNS-MDI/deep-seated-CDI from FUO with 56% sensitivity and 90% specificity. PCT was >500 pg/ml in only 10% of FUO (688, 570-771). A PCT peak >500 pg/mL (1196, 524-11950) occurred beyond 3 days of persistent fever in 17/21 (81%) invasive fungal diseases (IFD). This late PCT peak identified IFD with 81% sensitivity and 57% specificity and preceded diagnosis according to EORTC-MSG criteria in 41% of cases. In IFD responding to therapy, median days to PCT <500 pg/mL and defervescence were 5 (1-23) vs. 10 (3-22; p = 0.026), respectively.Conclusion: While procalcitonin is not useful for diagnosis of infection at onset of neutropenic fever, it may help to distinguish a minority of potentially severe infections among FUOs on day 2 after onset of fever. In persistent fever monitoring procalcitonin contributes to early diagnosis and follow-up of invasive mycoses

Asymptomatic high flow subclavian steal in a patient with hemodialysis access.

Subclavian steal phenomenon due to proximal subclavian artery stenosis or occlusion is not un-common but often remains asymptomatic. We describe the case of a 66-year-old man with end-stage renal disease hemodialysed through a brachio-brachial loop graft of the left forearm. Echo-Doppler precerebral examination showed a high reversed flow of 570 ml/min in the ipsilateral vertebral artery. After successful endovascular recanalization of the subclavian artery, access blood flow increased and vertebral flow decreased to 30 ml/min. Complete neurological examination was normal both before and after endovascular treatment. This case demonstrates how high a subclavian steal can be without causing symptoms and how well precerbral and cerebral circulation can adapt to hemodynamic changes.

Papyrus Prisse. Egyptien 190. Enseignement de Ptahhotep (298-373)

Vers 298 à 373.Fin de la 19e maxime, maximes 20 à 24 et début de la maxime 25.